Endoscopic findings of radiation ileitis.

I herein report a case of radiation ileitis. Ileocolonoscopy disclosed villous edema and multiple patchy lymphangiectasias in the terminal ileum. While observing, active bleeding occurred from the numerous telangiectasias and friable atrophic mucosa. Clinical manifestations of radiation ileitis are briefly discussed.

Effectiveness of ultrasound in the differential diagnosis of ileitis detected by computed tomography.

CASE REPORT A 86-year-old man with a recent history of stent placement for infrarenal aortic aneurysm arrives to the emergency department with abdominal pain. Computed tomography (CT) is performed to rule out complications of the endovascular procedure. The CT showed a loop of ileum with decreased caliber, fat trabeculation and hypervascularity causing proximal dilatation. No signs of ischemia or complications related to the prosthesis were observed. He was admitted to our service due to findings of non-specific ileitis. An intestinal ultrasound was performed and revealed a short segment of proximal ileum with pathological wall thickening with an intraluminal birefringent filamentary hyperechoic material (foreign body), which crossed all the layers of the wall. In the following days serial ultrasounds were performed showing that the foreign body remained in the same location and it was decided to perform surgery. During surgery the foreign body turned out to be a blister which conditioned an ileitis. Finally, intestinal resection was performed and the patient presented good clinical evolution. DISCUSSION The most validated technique for the diagnosis of foreign bodies is CT (1). However, intestinal ultrasound could help in its identification, especially for the non-radiopaque ingested material. On the other hand, it is especially useful in the pediatric age, where exposure to ionizing radiation should be avoided (2,3). In our case, it allowed not only to establish the diagnosis immediately but also to evaluate the evolutionary behavior of the same in terms of its mobilization or detection of local complications.

One appendix too many: a severe IBD-U case in remission after appendectomy.

A 39-year-old female was diagnosed with inflammatory bowel disease unclassified (IBD-U) in 2011, during the post-partum period, after developing chronic bloody diarrhea and marked weight loss. She underwent colonoscopy showing erosive ileitis and pancolitis. Biopsies were compatible with unspecified chronic ileocolitis.

Valor de la ecografía abdominal en la evaluación de la ileítis infecciosa aguda en niños / Value of abdominal ultrasound for evaluation of acute infectious ileitis in children

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Subacute distal ileitis in a healthy young adult.

A previously healthy 36-year-old male presented with pain in the right lower abdomen associated with weight loss, diarrhea and fever, after suffering blunt abdominal trauma during a vehicular collision 4 weeks earlier. An explorative laparoscopy was performed. A plastron composed of the appendix, caecum and 30 cm of small bowel loops was found.

Bowel wall thickening and hyperemia assessed by high-frequency ultrasound indicate histological inflammation in Crohn's ileitis.

PURPOSE: We evaluated ileal bowel wall thickness and semiquantitative vascularization by ultrasound in correlation with the presence or absence of histopathological inflammation in patients with Crohn's disease (CD). METHODS: We conducted a retrospective analysis of 221 ultrasound examinations of the terminal ileum or neoterminal ileum in CD patients with biopsies of the ileum during colonoscopies within 8 weeks of the ultrasound. Ultrasound data were obtained from an inflammatory bowel disease ultrasound register from 2011 to 2017. Bowel wall ultrasound was performed by a high-frequency, linear transducer (7-12 MHz). Presence of bowel wall thickening (> 3 mm), vascularization by the Limberg score, and presence of ileal histopathological inflammation were analyzed. RESULTS: In 221 bowel wall ultrasound examinations of CD patients (128 female, 93 male, mean age 37.5 years), a thickened bowel wall was found in 140 (63.3%) and hypervascularization (corresponding to a Limberg score ≥ 2) in 96 (43.4%) cases. In 187 (84.6%) cases, ileal inflammation was confirmed by histopathology and in 34 (15.4%) cases no inflammation was shown. Bowel wall thickening showed a sensitivity of 70.1%, a negative predictive value (NPV) of 30.9%, a specificity of 73.5% and a positive predictive value (PPV) of 93.6% for the detection of histopathological ileal inflammation. Hypervasularization had a low sensitivity (49.7%) and NPV (24.8%), but high specificity (91.2%) and PPV (96.9%). CONCLUSION: In this CD subcohort of an ultrasound register, pathologic ultrasound findings were quite common. Bowel wall thickening (> 3 mm) and hypervascularization are good predictors of histopathological inflammation within the terminal ileum or neoterminal ileum. Normal ultrasound findings without bowel wall thickening and without hypervascularization do not rule out histopathological inflammation.

FDG-PET-CT Enterography Helps Determine Clinical Significance of Suspected Ileocecal Thickening: A Prospective Study.

BACKGROUND: Ileocecal thickening (ICT) on imaging could result from diverse etiologies but may also be clinically insignificant. AIM: Evaluation of role of combined 2-deoxy-2-fluorine-18-fluoro-D-glucose(18F-FDG)-positron emission tomography and computed tomographic enterography (PET-CTE) for determination of clinical significance of suspected ICT. METHODS: This prospective study enrolled consecutive patients with suspected ICT on ultrasound. Patients were evaluated with PET-CTE and colonoscopy. The patients were divided into: Group A (clinically significant diagnosis) or Group B (clinically insignificant diagnosis) and compared for various clinical and radiological findings. The two groups were compared for maximum standardized uptake values of terminal ileum, ileo-cecal valve, cecum and overall. RESULTS: Of 34 patients included (23 males, mean age: 40.44 ± 15.40 years), 12 (35.3%) had intestinal tuberculosis, 11 (32.4%) Crohn's disease, 3 (8.8%) other infections, 1 (2.9%) malignancy, 4 (11.8%) non-specific terminal ileitis while 3 (8.8%) had normal colonoscopy and histology. The maximum standardized uptake value of the ileocecal area overall (SUVmax-ICT-overall) was significantly higher in Group A (7.16 ± 4.38) when compared to Group B (3.62 ± 9.50, P = 0.003). A cut-off of 4.50 for SUVmax-ICT-overall had a sensitivity of 70.37% and a specificity of 100% for prediction of clinically significant diagnosis. Using decision tree model, the SUVmax-ICT with a cut-off of 4.75 was considered appropriate for initial decision followed by the presence of mural thickening in the next node. CONCLUSION: PET-CTE can help in discrimination of clinically significant and insignificant diagnosis. It may help guide the need for colonoscopy in patients suspected to have ICT on CT.

From terminal ileitis to Crohn's disease: how capsule endoscopy is crucial to diagnosis.

BACKGROUND AND AIMS: Terminal ileitis is a common condition and may be associated with a wide variety of diseases, mostly Crohn's disease. Although small bowel capsule endoscopy (SBCE) is a valuable diagnostic tool for small-bowel diseases, data regarding its diagnostic impact on isolated terminal ileitis are sparse. The aim of this study was to evaluate the diagnostic value of SBCE for isolated terminal ileitis detected during ileocolonoscopy and to assess predictive factors for Crohn's disease diagnosis. METHODS: This is a retrospective study including consecutive patients undergoing SBCE after diagnosis of terminal ileitis without colonic mucosal abnormalities on ileocolonoscopy between January 2016 and September 2019. RESULTS: This included 102 patients with isolated terminal ileitis on ileocolonoscopy. Positive findings on SBCE were found in 82.4% of patients. After performing SBCE, 61.8% of patients had a final diagnosis, being Crohn's disease the most common (34.3%), followed by NSAIDs enteropathy (12.7%). Extraintestinal manifestations (P = 0.003), weight loss (P = 0.02), abnormal imaging (P = 0.04) and positive SBCE findings (P = 0.001) were independently associated with Crohn's disease diagnosis. Regarding SBCE, presence of proximal small-bowel disease (P = 0.02), diffuse findings (P = 0.002) and moderate to severe inflammatory activity (Lewis score ≥ 790) (P < 0.001) were independently associated with Crohn's disease diagnosis. CONCLUSION: SBCE is a valuable tool that should be systematically used in patients with isolated terminal ileitis on ileocolonoscopy, since it revealed a high diagnostic yield, supporting a definite diagnosis in almost two-thirds of patients, and Crohn's disease diagnosis in approximately one-third of patients. A diagnosis of Crohn's disease should be considered when a patient with terminal ileitis on ileocolonoscopy shows proximal involvement, diffuse findings and/or moderate to severe inflammatory activity on SBCE.

Terminal Ileitis Presenting With a Spontaneously Reduced Ileocolic Intussusception Diagnosed by Point-of-Care Ultrasonography.

Point-of-care ultrasound can be used in the initial workup of ileocolic (IC) intussusception. In general, these lesions require immediate attention and reduction to prevent ischemic bowel injury. We discuss the case of a 27-month-old boy whose IC intussusception was found to spontaneously reduce before a radiology performed ultrasound and the planned air enema reduction procedure. Radiology ultrasound revealed significant inflammatory changes of the terminal ileum. The incidence of spontaneous reduction of IC intussusception is not definitively known. It is important to be familiar with the possibility of spontaneous reduction as children are often referred to academic centers for radiological or surgical reduction. This may also impact the sensitivity of studies that evaluate test characteristics of point-of-care ultrasound compared with radiology performed ultrasound for the diagnosis of IC intussusception. We review the diagnostic technique for IC intussusception and the importance of a prereduction ultrasound immediately before image-guided pressure reduction attempt.

Ileítis isquémica idiopática, con sangrado digestivo oscuro manifiesto / Idiopathic ischaemic ileitis, with overt obscure digestive bleeding

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A Toothpick a day, keeps the doctor away?

A Toothpick is a dreaded offender when ingested, as it is risky to cause impaction, obstruction or perforation of the gut. When ingestion of a toothpick leads to one of these complications, it clinically mimics an acute abdomen. Often the patient doesn't recall the ingestion, leading to misdiagnosis as inflammatory bowel disease, appendicitis/diverticulitis, etc. We describe the case of a 50-year old woman presenting to the emergency department with right lower abdominal pain. CT-scan showed an obstruction without clear underlying cause. The hypothesis of obstruction due to intestinal adhesions without strangulation was assumed and non-operative management lead to recovery and dismissal of the patient. However, she presented 3 weeks later with identical complaints, this time showing a terminal ileitis on CT-scan. Surprisingly, a toothpick perforating the terminal ileum was found during endoscopy and could by removed. A clinician should think of foreign body ingestion when patients present with an acute abdomen with no clear underlying pathology.

Hepatic portal venous gas associated with Klebsiella oxytoca infection in the absence of preceding antibiotic treatment.

Klebsiella oxytoca (K. oxytoca) is a causative organism for hemorrhagic antibiotic-associated colitis. K. oxytoca infection is a typical example of microbial substitution diseases caused by exposure to antibiotics prior to the onset of diarrhea. Here, we repot a case with ileitis associated with K. oxytoca infection in the absence of preceding antibiotic treatment. Interestingly, abdominal computed tomography revealed wall thickening of the ileum and hepatic portal venous gas (HPVG). K. oxytoca was isolated from the stool. This very elderly patient had been treated with azathioprine for long-standing history of ulcerative colitis. Immuno-compromised state of this patient was considered to allow overgrowth of K. oxytoca in the small bowel to cause not only ileitis but also HPVG.

Backwash ileitis in ulcerative colitis: Are there MR enterographic features that distinguish it from Crohn disease?

OBJECTIVE: To reveal the MR enterography (MRE) findings that distinguish backwash ileitis (BWI) from terminal ileitis due to Crohn's disease (CD) and to determine the usability of barium studies manifestations (ileocecal valve (ICV) gaping, terminal ileum dilatation) in MRE for the diagnosis of BWI in ulcerative colitis (UC) patients by pointing at the diagnostic performance of these imaging findings. SUBJECTS-METHODS: The study population consisted of patients who were diagnosed as ulcerative colitis (UC), and underwent 1.5 T MRI between August 2011 and November 2017 to rule out small bowel involvement. The matched controls were comprised of Crohn's patients examined at the same period. Ileocolonoscopic/ histopathologic findings were accepted as reference standard. Mural/extramural changes in bowel segments, ileocecal valve (ICV) gaping, terminal ileum dilatation, restricted diffusion and anatomical extent of involvement were evaluated. In UC patients, the association between ICV gaping and terminal ileum dilatation and BWI was assessed by χ2 test. The diagnostic accuracy of these two findings in BWI was determined. RESULTS: Sixty patients were included in the study (30 UC; 30 CD; mean age, 43 years in both groups). Ileocecal valve gaping and terminal ileum dilatation were significantly more frequent among BWI patients (p < 0.001) in UC. Patients with BWI showed a higher rate of pancolitis (88.9%). Median terminal ileum wall thickness was found to be significantly greater in patients with CD (p < 0.001). CONCLUSION: In patients with definite diagnosis of UC, ileocecal valve gaping and terminal ileum dilatation suggest the development of BWI. However, these findings cannot be use to differentiate cause of terminal ileitis in patients with unconfirmed diagnosis and do not give reliable information about the causative factor of ileitis.

Tuberculosis intestinal, simulador de la enfermedad de Crohn: diagnóstico diferencial / Intestinal tuberculosis simulating Crohn's disease: Differential diagnosis

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